Employment Application

Transcription

1 Employment Application Personal Information Name: _Date:_ Present Address:_ :_ Permanent Address (If different than present address): If you cannot be reached at the above phone, where can we reach you?_ Employment Desired Type of W ork Desired Wage Shift Where did you learn about this position?_ Will accept Employment of: Full Time Part Time Temporary What hours are you available for work?_ Date Available: _ or Are you a United States Citizen? If not, do you have a W ork Permit? Do you have a valid Driver s License? Were you previously employed by us? If yes, when? Reason for separation of employment:_ List any Friends or Relatives working for us. Name Person to contact in case of an accident or emergency: Person to contact in case of an accident or emergency: Relationship Name Relationship Name Relationship

2 Education/Training School Name / Address of School Courses Taken Graduate? Date Diploma, Degree, or Certificate High School College Other Training (Please Specify) Other Classes/Training: Extracurricular Activities While in School: Area of Specialization or Major Interest: Professional Organization Memberships, Honors Received, Volunteer or Community Service, or Other Qualifications You Have Which You Feel Are Related to the Position Which You Are Applying For:

3 Professional Licenses and/or Certifications RN/LPN s State Nursing Assistant: Are you currently on the Minnesota Registry? Pending Social Security : - - (For Registry Confirmation) Other states where registered: Additional Professional Licenses and/or Certifications Type Organization or State Issued Date Issued Verification Type Organization or State Issued Date Issued Verification Type Organization or State Issued Date Issued Verification Military Record Military Branch Are you currently active in the Military? Date Entered Specialized Training: List any Service Awards or Commendations: Separation Date(s) Military Occupational Specialty Rank at Discharge:

4 Employment History List current (or most recent) Employer first and all others in reverse chronological order.

5 References List Three References Who Are t Relatives Or Former Employers. Name and Occupation Address Telephone In a few sentences or a short paragraph, please tell us why you would like to work for this organization.

6 Employment Understanding (Please Read and Sign.) This organization does not discriminate in hiring or any other decision on the basis of race, color, sex, citizenship, national origin, ancestry, veteran status, or on the basis of age or physical or mental disability unrelated to ability to perform the work required. question on this application is intended to secure information to be used for such discrimination. I voluntarily give this organization the right to make a thorough investigation of my past employment and activities, agree to cooperate in such investigation and release from all liability or responsibility all persons, companies or corporations supplying such information. I consent to take a physical examination and such future physical examinations as may be required by this organization at such times and places as the organization shall designate. I understand that an offer of employment may be contingent on the ability to perform the physical strengths which relates to the essential duties I would be required to perform. I understand that my employment is at will, and that either party is free to terminate the employment relationship at any time without cause. I hereby affirm that the information provided on this application (and accompanying resume, if any) is true and complete to the best of my knowledge and agree that falsified information or significant omissions may disqualify me from further consideration for employment and may be considered justification for dismissal if discovered at a later date. If employed, I will be required to complete an Employment Verification Form (I-9) and within three days show satisfactory evidence of identity and eligibility for employment. I understand that this organization operates seven days a week, 24-hours-per-day and the primary concern in scheduling staff is consistent, quality care for residents. Meeting this commitment may mean I will be asked to work at times and in areas not usual to my schedule. I agree to such scheduling. Applicant s Signature Date If you have more information, a cover letter, or a resume, please attach to your along with the application.

7 Employment and Reference Check Applicant - DO NOT write on this page. (For Interviewer s Use) Person Contacted Date (MM/DD/YEAR) Staff Initials Reference Cleared List Position Offered (Example:.8, CNA, Afternoon) Status Position Wage Scale Reviewed Staff Printed Name Staff Signature Date (MM/DD/YEAR) Experience Verified Date (MM/DD/YEAR) Shift Starting Wage Rate